Archive for the ‘Postpartum Psychosis’ Category

Two thunderous standing ovations highlighted this year’s APA meeting. They were as different as you could imagine. An intimate conversation with Brooke Shields about her battle against nature’s cruelest mood disorder – postpartum depression – and Dr. John Nash (A Beautiful Mind) reading a paper he wrote in which he describes his battle against schizophrenia through metaphors of economic theory and the complex mathematics of game theory (for which he received a Nobel prize). Each presentation was in front of hundred’s of physicians and other professionals. One was alternately funny and gut wrenching. The other was a mind twisting exercise in obfuscation.

What they had in common was each individual had the courage and strength to open their heart and soul to the professional world so that their stories could help us help others.

Dr. Nash’s presentation was interesting at times and touching at times but mostly unemotional. I wish he had been interviewed in front of the audience instead.

He likened becoming psychotic to part of his mind going on strike. The most provocative thing he said was that to him his new insight into mathematics and his paranoia were both novel ideas not shared by anyone. The only difference was that one was true, was labeled genius, and was rewarded with the Nobel prize. The other was not true, was labeled insanity, and got him committed to a locked psychiatric ward.

The schizophrenic mind can’t tell the difference. Of course sometimes ideas are true but sound crazy. And for various reasons society is not ready for them and may even persecute those who dare to challenge the current version of truth (like the earth is the center of the universe).

I was the most moved by Brooke Shields. Maybe because I have helped women who struggle with postpartum depression for over 40 years.

What can possibly be a more joyous time than having a new baby – looking into your eyes, cooing, and responding to your love? What can be more painful than when you as a mother feel nothing, or rejection, or thoughts of harming this poor helpless creature? What could be more shameful and guilt producing?

Everyone is saying how cute and precious your baby is, and you’re thinking "I wish you would shut up," or maybe even, "Please take this baby with you." And if you do share that you’re not feeling right they say, "Oh, it’s just ‘baby blues.’ It will pass. it’s normal."

And you’re thinking, "You don’t understand. I want to die. I feel empty, hopeless, inadequate, overwhelmed." Or if they suggest medication, what you hear is you’re weak or crazy or both! When you’re a celebrity with fame and fortune, a loving husband, and all the trappings of a perfect life, but you feel like a total failure, you see no hope for even being o.k. again and thoughts of suicide come to mind.

As Brooke Shields discussed this torturous beginning to motherhood, the pain of her experience was palpable throughout the ballroom. The first turning point occurred for her when she had sent her husband to get a changing table, but he returned empty handed. He sat on the bed and broke down. She had never seen him cry. He said "I went to the store and there were all these mothers and babies and families, and they were so happy. Why aren’t we happy?"

I almost lost it, in fact it took several tries before I could comment to my wife without getting choked up.

She went on to describe how she got on an antidepressant and felt better. She went back to California and stopped the meds and crashed again. She describes driving in her car with the baby in the back and thinking, "I could speed up to 80 mph and run into a concrete wall and all this would be over." Fortunately she called a girlfriend and told her how she was feeling, and her girlfriend made a date with her for lunch the next day. She said her girlfriend was so manipulative because she knew Brooke was compulsive about keeping her commitments and would have to wait until after lunch tomorrow to drive into a wall.

Brooke called her doctor who asked if she had stopped her meds. She said yes and he asked, "Why?" She thought, "Did I sleep through my 4 years at Princeton?"

So, she went back on meds, had some side effects, changed meds, and eventually, everything was okay.

3 years ago she went through a 2nd pregnancy without all the stressors of her first pregnancy, which included 7 in vitro fertilizations, miscarriages, death of her father (prostate cancer), an emergency C-section, being away froms support people, and being clueless with expectations of being the perfect mother.

She described how different this 2nd experience was. When the OB handed her the baby in the delivery room, her husband was thinking "Please don’t start sobbing," but she felt joyous, relieved, then elated. She said, "I started telling my girlfriends they could have some of my husband’s sperm (in vitro) if they needed it." A happy ending.

She tells her story in the recent book Down Came the Rain. She has done way more than her share in making women aware of what can happen and that treatment is available. I felt so much respect and appreciation for what she has done. Then I thought about Tom Cruise (see previous article). I wondered how many women were on the fence about mood disorders, psychiatry, and medication. How many were influenced by him to not seek help? How many mothers suffered unnecessarily, and how many babies didn’t bond with their mothers during those early critical developmental weeks and whose lives will be adversely affected forever?

At the same moment I wanted to sing Brooke Shields praises and kick Tom Cruise’s ass.

What do we know about the cause of postpartum psychosis?

Hormones, especially estrogen, have a significant effect on mood. Estrogen raises serotonin. When estrogen drops precipitously, as it does premenstrually, postpartum, and at the onset of menopause – the brain serotonin levels drop. In women who are sensitive to low serotonin (because of genetics or previous episodes of significant depression) dropping the level will bring on symptoms of depression.

This principle can be demonstrated experimentally. By giving someone a drink of amino acid (from which tryptophan has been removed) the level of brain serotonin will temporarily go down. This is because tryptophan is the amino acid the brain uses to make serotonin. Only people with a vulnerability to becoming clinically depressed will show a depressive response to the serotonin level drop. This phenomenon contributes to premenstrual depression and menopausal (especially perimenopausal) depression.

Think about how dramatically hormone levels drop after child birth. This is why postpartum blues (brief symptoms of mild depression) is extremely common. The postpartum period is the highest risk period for full blown clinical depression.

Post partum psychosis is an extreme form of mood disorder in which underlying genetic vulnerability causes not only depression but a psychotic state. This fortunately only occurs in 1 out of 1000 births.

Psychosis is often confused with delirium. Delirium is a state of severe confusion and disorientation that can be brought on by toxins, severe infections, and many other causes. Every area of functioning is impaired. Psychosis means there is a distortion between conscious reality and external reality.

The most common symptoms of psychosis are hallucinations (seeing things or hearing things that aren’t there) or delusions (beliefs that aren’t true). A person can have one serious delusion that can affect their behavior but can be totally normal in other areas of functioning.

A woman who has had one postpartum psychosis is at a very high risk in any future pregnancies. It was for this reason that Andrea Yates was advised not to have any more children. So why did she and her husband ignore this? I don’t presume to know all the factors that they took into account. But I know she was never diagnosed as bipolar. And they were never adequately educated about the physiology and medical science that we do have about what causes postpartum depression and psychosis.

Another factor in the Yate’s decision to continue to have children was their faith. They relied more on spiritual experience and counseling with their minister than medical advice. Unfortunately they had come under the influence of an extremist minister, and their medical advice was inadequate and not convincing.

Can they be faulted for not realizing all of this? I think not. It is not unusual for a person of strong faith to at times feel caught between science on the one side and their faith on the other.

Many centuries ago St. Augustine showed more wisdom in this matter than many of our current experts. He said in effect science and religion aren’t in opposition. They are both ways of looking at and understanding one truth. When science and religion don’t agree we need to discourse and study so that the disagreement can be resolved – without feeling like you have to choose one or the other. Of course not all supposed science is valid and not all ministerial counsel can be trusted. Extremism of any type is dangerous.

“They found Andrea Yates not guilty,” my receptionist said to me Wednesday afternoon. I was delighted and surprised. I felt proud to be a Texan. Twelve jurors were able to do the right thing in spite of an almost impossible legal standard complicated by obstacles and hurdles imposed by a system that has the intellectual sophistication of the dark ages. The political powers changed the rules after Hinckley was found not guilty by reason of insanity for shooting President Reagan. Politicians and ultimately judicial officials pander to the vote – that’s the system.

Wednesday night the backlash began. I like Nancy Grace – the popular CNN Headline News Channel’s attorney/program hostess. She is tough but I usually agree with her. She is willing to take on any issue or individual and challenge the system in desperate need of repair. But on her Wednesday night show she was in la la land. She acted like a trial lawyer with their client (in this case the five murdered children) but dehumanized the opposing side, in this case Andrea Yates. Her position was that Andrea Yates was stressed out by taking care of five small kids and being trapped at home all day so she murdered them to make her life easier. Give me a break. Yates immediately called the police, told them what she did, she knew she was going to prison; she probably even thought she would be put to death – this is making your life easier?

On Thursday night I was speaking to a group of physicians and pharmaceutical reps in Lubbock, Texas. I asked, “How many of you are happy with the Andrea Yates verdict?” Only one doctor raised his hand. The overwhelming majority thought she is guilty and should spend the rest of her life in prison.

Then, on Prime Time Thursday night on ABC, they showed one of the prosecution’s “expert witness” psychiatrists interviewing (badgering) Yates on video tape having her retell detail by detail the horrible scenes that will forever torture her mind. He was splitting hairs in an apparent attempt to trap her into telling what he thought was the truth – that she planned and carried out a cold blooded murder of her children because she was tired of the strain of motherhood. What an idiot. He impressed me not as an insightful, empathic physician but as a member of the oldest profession.

On the brighter side, The Dallas Morning News editorial on Thursday morning supported the verdict and noted that they were reversing their position from their earlier support of the guilty verdict. Friday morning the USA Today editorial headline read, “Yates verdict reflects a healthy evolution.” They applaud the new verdict and conclude that “society has come a long way since the acquittal of Hinckley…” They also added that the law needs to come a bit further. I’m afraid it’s going to take more than a bit.

Why is there so much confusion? How can intelligent caring people be so polarized?

I am totally convinced that nothing is going to change until the majority of voting citizens clearly understand the issues and support a separate handling of individuals like Andrea Yates who is in almost every way the opposite of a criminal.

Only when public opinion changes will politicians change the rules. Is it possible to change people’s minds? Yes, most people want to do the right thing.

We need to start with the word guilt. When most of us ask ourselves “is she guilty?”, we mean “did she do it and did she do it on purpose?” Included in that is “did she know what she was doing?” The law defines guilt more strictly in terms of “being responsible for her act.” This use to mean knowing it is wrong and being in control of your behavior – but post Hinckley it was changed to just knowing it was wrong.

Some states have already changed the language to the more appropriate option of “guilty and insane.” We need to have a national standard that reflects this more accurate and comprehensible description of severe mental illness and legal accountability. A verdict of guilty and insane should not be “you’re free to go, have a nice life.” It should mean you go to a locked psychiatric treatment facility where you are treated as long as necessary, perhaps for life. It should mean that if you are released it is under the close monitoring of the judicial system for as long as necessary, commensurate with the crime. Whatever enforcement monitoring is necessary to assure protection for all concerned is feasible and should be a mandatory component.

Another problem that unnecessarily made the Yates jury’s decision more difficult is that they were not allowed to know what would happen to her if they found her not guilty. For all they knew she could have walked out the front door. This is ostensibly so that they make their decision based strictly on the law (with all its nebulous and abstract concepts). They should not be deciding based on the practical element of “what difference does it make what we decide?” Why not? Because despite the iconic balanced scales, the law is not about logic or fairness, it’s about “what are the facts and what is the law?”

In fairness, Andrea Yates did not meet the Texas law’s standard for criminal insanity. She knew what she was doing was against the law, and she knew she would be punished. She also knew it was against God’s law and the commandments. She believed that by killing her children she was sacrificing her life and her soul to save theirs. She felt responsible for them being bad kids (misbehaved) on the wrong path. In fact, Pastor Michael Woroniecki often quoted from the gospel of Mark, “whoever causes one of these little ones to stumble, it would be better for him if, with a heavy millstone hung around his neck, he had been cast into the sea.” She had attempted suicide twice because in her mind that would be protecting her children from her bad mothering. How ironic that it was the ultimate sacrifice of a mother for her beloved children.

Basically the jury decided – we don’t care what the law says, this woman was (and still is) crazy, psychotic. She is not a criminal – what she needs is help not punishment.

It’s hard to put yourself in someone else’s shoes. One of the best definitions of empathy that I’ve heard is: can you tell the other person’s story from their point of view? (which does not mean you agree with their thinking or that you approve of their behavior.) How can you imagine being insane? The closest I think you can get is to think about how your mind works when you are dreaming – random, weird, sometimes scary. That’s how a psychotic person’s mind works when they are awake. They cannot control their mind – it controls them.

What kind of a person is Andrea Yates? She is the opposite of a criminal. She was an R.N. She has been described by people who know her well as one of the most selfless and giving people they know. When her father was sick and dying, she’s the one who was taking care of him in addition to taking care of her own five kids. When someone in the neighborhood was sick, she’s the one that prepared meals for them. Her ex-husband, who also lost his five kids, has never wavered in his support for her. He knows that she killed the children out of love and psychosis. What possible criminal motive could she have had? She didn’t try to get away with anything – she immediately called the police.

To really understand the ordeal that she and her whole family went through you should read the excellent book, Are You There Alone?: The Unspeakable Crime of Andrea Yates, by Suzanne O’Malley. They went through years of suffering and medical mismanagement. It has been known for at least 10 years that postpartum psychosis is a rare complication of childbirth and that it is almost always a form of bipolar disorder (the old term is manic depressive).

For centuries throughout the world, new mothers in a state of insanity have murdered their babies. The U.S., to my knowledge, may be the only industrialized advanced country that considers it murder.

We have known for years that patients with bipolar disorder are made worse by antidepressants – unless they are on adequate doses of mood stabilizers or at least on an antipsychotic. Yates had been on Haldol (an older harsher antipsychotic – but more acceptable to insurance companies because it’s in generic), but even that had been stopped. When she killed her children she was on just antidepressants. Whose fault is that?

Yates had been hospitalized on several occasions, but kicked out early due to insurance company pressure. The hospital unit she was last treated on was for drug addicts, where she was forced to go to group therapy and lectures about addiction. How useful was that? Whose fault was that?

Ironically again, she was a devout Christian who was unduly influenced by a lunatic minister who repeatedly burdened her with guilt and impossible standards by which she was to judge the mental/spiritual health of her children. The thread of extreme fundamentalism seems to appear too often in cases where mothers kill their babies.

Could the influence of extreme “spirituality” on someone with the genetics of bipolar disorder contribute to the loss of control by the rational part of the mind?

There is no question that five children tragically lost their lives, but who/what is really to blame? Is it the system, the minister, the insurance companies, the hospitals, the doctors? Some people blame the ex-husband. When I review all the facts I see him as one of the victims. Maybe he relied too much on faith. Maybe he didn’t scream loud enough when her treatment wasn’t working. But I believe he did everything he knew to do.

If all the discussion and TV specials (that attract a lot of viewers and make the networks a lot of money) ultimately lead to greater understanding, then a change in public attitudes and a change in laws might happen. Then the death of five children will not have been in vain. The best outcome would be for a greater awareness to lead to early diagnosis and effective treatment for postpartum psychosis so that future babies aren’t the victims of Dark Age mentality in the 21st century.

Guilt is feeling bad because you hurt someone else. Shame is feeling bad because you don’t live up to your own standards and values. Shame is what the system should feel for not protecting the five children of Andrea Yates. Shame is what the system should feel for letting her sink deeper and deeper into the depths and torture of psychotic hell. Shame is what the system should feel for rubbing her nose in it over and over and parading her around like a freak show exhibit.

Shame on everyone who contributed to the problem or exploited it for personal or financial gain.

Andrea Yates, her ex-husband Rusty, and all their family and friends will suffer the rest of their lives because babies of mothers with postpartum psychosis don’t have a lobby group and can’t vote. Let’s change the system!

The Supreme Court this week turned their back on patients with severe psychiatric illness – as in “we ain’t lettin’ no crazy people off the hook.” They also turned back toward the dark ages where psychosis was thought of as totally mysterious, or demonic possession.

After reviewing a case where a 17 year old paranoid schizophrenic boy fatally shot a police officer in Flagstaff, Arizona, the Supreme Court let stand the guilty verdict of the Arizona court. In 1993, Arizona passed a new insanity defense law that made it virtually impossible to qualify as insane. The judge in Arizona refused to allow testimony from psychiatric experts about the characteristics of mental illness.

The Supreme Court by a 6-3 vote ruled that Arizona has the right to restrict the insanity defense as long as they don’t deny him or her due process – say what? They also defended the courts right to not allow psychiatric testimony because “there is considerable disagreement within the profession, and experts often disagree in court testimony.” Excuse me, but if court testimony is not allowed when there is disagreement in the area and experts disagree, we should just board up all the court houses.

The most disappointing thing to me is that the highest legal authorities in the land had an opportunity to move us in the direction of being not only more scientific but more humane, and they just didn’t get it.

Many of the more advanced countries in the world have gradually changed their laws to incorporate the advances in the understanding of the “broken brain.” The U.S. on the other hand, changed the laws to severely restrict the insanity defense. This was another example of a knee-jerk response to an event – in this case, John Hinckley being found not guilty for reason of insanity after he shot President Reagan. Rather than educate the public about mental illness we change the laws so that they will keep the congressmen in office.

A new jury is currently being subjected to the horrifying details of Andrea Yates’ murder of her five children. They will have a difficult decision because although her motivation was totally insane, she knew it was against the law. In Texas, as in many other states since the Hinckley ordeal, this makes her guilty of capital murder – only an overzealous prosecution expert witness kept her from the death penalty.

The legal system has again failed and is directly responsible for the hung jury in Collin County, Texas. The Dallas Morning News front page article for Friday, 2-24-06 reads "Jurors deadlocked in Plano mother’s murder trial."

This whole story is so bizarre, that unlike the recent memoir "Pieces," this one couldn’t have been made up. Ironically, the most bizarre part of the story for me is the closing statement by the prosecutors. But first, I need to paint the setting.

A jury of 5 women and 7 men have had to endure a long painful trial. They have spent over 21 hours in 2 days deliberating, unable to reach consensus. The facts are not in dispute. In November 2004 Dena Schlosser cut off her 10 month old daughter’s arms at the shoulder. (related December 2004 blog) The jury has to decide unanimously whether she is guilty of murder or not guilty by reason of insanity. What I think is insane is the law that forces the jurors to make that choice.

There is no question that Ms. Schlosser had a severe mental illness with delusions, hallucination, and bizarre behavior that came on during the postpartum period. She had somewhat brief and inadequate psychiatric treatment. She was also a strongly religious person whose preacher doesn’t believe in mental illness and attributed her sick behavior to demons. Her husband was similarly clueless.

The defense put on several witnesses, including psychiatrists, who said she was insane and didn’t know right from wrong. In what appeared to be a concession, the prosecutor did not put any mental health witnesses on the stand to dispute the insanity defense. Maybe they couldn’t find a single mental health professional who agreed with them.

In their closing statements, prosecutors told the jurors that the psychiatrists who testified for Ms. Schlosser made their decision before they examined her. Quoting The Dallas Morning News article,

"They said the crime was so horrible that the psychiatrists, like many people, already believed that only someone not in her right mind would sever a baby’s arms."

Excuse me if I’m missing something. Can anybody think of a scenario where a woman IN her right mind would commit such an act? And the ulterior motive was ….?

The problem is the legal options. Ms. Schlosser IS GUILTY … BY REASON OF INSANITY (according to the law, this option does not exist). She needs to be in a psychiatric treatment facility. Her treatment needs to be monitored by the court, and if she’s ever deemed able to be released, her ongoing treatment would need to be continued for life – with parole revoked if she doesn’t comply. One option would be controlling her psychosis with mandatory injections, which are long acting and given monthly.

To add misery to insult, the jury is being put on a guilt trip. The judge told them if they didn’t make a unanimous decision, another trial and jury might not either. It would cost the tax payers a lot of money to retry her case.

They have already told the judge there is no chance they will all agree. That means to get a verdict, at least one of them will have to vote against their conscience and then have to live with that too. Wasn’t going through this trial traumatic enough? At least the law was recently changed to allow the prosecutor and defense attorney to negotiate an agreement, presumably "not guilty by reason of insanity." Be honest, is this nuts or what?

Please, somebody wake me up and tell me I’ve been having a bad dream. I didn’t just read that the District Attorney in Collin County has charged a Plano woman, Dena Schlosser, with capital murder. She can be put to death for taking a phrase in the Bible literally and cutting off her baby’s arms. It couldn’t also be true that Child Protective Services is not letting her husband have his other two traumatized, confused kids for just the opposite reason. He didn’t take his wife literally when she told him the night before the incident that she was giving the baby to God. He is being punished because he didn’t know his wife was insane before she carried out an obviously psychotic act. But the district attorney hasn’t figured it out, even after the act.

The reason I know that I’m dreaming is that this is 2004. Our government officials couldn’t be that obtuse. How could they expect the husband to take his wife literally? Even in the Bible, when Samuel’s mother said she was giving her son to God, she meant she was dedicating his life to God’s work. I guess if the CPS officials came to a fork in the road – they would eat with it.

Our officials need to make up their minds. They can’t have it both ways. You can’t expect the wife to think metaphorically and the husband to think literally. As a New York newspaper chief editor (and crusty Texan) told his fence riding journalist, "Don’t pee down both legs at the same time." So what’s the problem? The problem is the law is out of touch with reality. I guess you could say the law is not sane. According to the law, there are two options – guilty OR not guilty by reason of insanity. But she IS guilty. She is guilty by reason of insanity.

Scott Peterson is a totally different story. He is obviously guilty by reason of severe narcissism and sociopathy. He has no conscience. Mrs. Schlosser, Andrea Yates, plus another woman in East Texas last year were all suffering from postpartum psychosis.

The percent of women who become clinically depressed in the few weeks after having a baby is ironically higher than at any time in a woman’s life. Fortunately, psychosis during this period is not common. It only occurs in about 1 in 1000 deliveries. Most of the time, women who develop postpartum psychosis turn out to be bipolar. This is a serious mood disorder that requires continuous treatment, just as does diabetes.

Most women who develop postpartum psychosis don’t murder their babies, but it is a well known possible complication. Most of the time, women who murder their babies lack adequate family network, have husbands who don’t provide enough emotional comforting, and they are usually involved in a fundamentalist church.

One classic symptom of psychosis is concrete thinking (i.e. taking everything literally). Have you ever had a really crazy dream? That’s the way the psychotic mind works when they are awake – and to them it seems real.

Fortunately, we have excellent medications to treat this disorder. Unfortunately, these medications are expensive and our "managed cost" medical system often only provides less expensive, less effective medication.

Let’s wake up from the dark ages. I believe the United States is the only country that treats infanticide during postpartum psychosis as a crime. Scott Peterson murdered his wife and unborn child because he didn’t want to be bothered by a child or child support. He planned it out carefully and tried to hide the fact from everyone. Dena Schlosser and Andrea Yates murdered their babies to send them to heaven. They immediately called someone to tell them what they had done. Am I crazy or do these two scenarios seem different?